Meta-Analysis of the Influence of Chronic Kidney Disease on the Risk of Thromboembolism Among Patients With Nonvalvular Atrial Fibrillation

Abstract

Chronic kidney disease (CKD) and atrial fibrillation (AF) frequently coexist. However, the extent to which CKD increases the risk of thromboembolism in patients with nonvalvular AF and the benefits of anticoagulation in this group remain unclear. We addressed the role of CKD in the prediction of thromboembolic events and the impact of anticoagulation using a meta-analysis method. Data sources included MEDLINE, EMBASE, and Cochrane (from inception to January 2014). Three independent reviewers selected studies. Descriptive and quantitative information was extracted from each selected study and a random-effects meta-analysis was performed. Thromboembolic events are one of the most feared complications of atrial fibrillation (AF). 1 Chronic kidney disease (CKD) is relatively prevalent in patients with AF. 2 The extent to which the presence of CKD may increase the risk of thromboembolism in patients with AF has not yet been fully elucidated. Oral anticoagulation is the mainstay of thromboembolic prevention in patients with AF, 3 but data on efficacy and safety in the CKD and dialysis population have been scarce and contradictory. 4,5 Our aim was to systematically evaluate, through a meta-analysis method, the impact of the presence of CKD in patients with AF as regards risk of thromboembolism and the potential benefit of anticoagulation in that setting. MethodsWe performed a search in MEDLINE (by way of Ovid and PubMed), EMBASE, and Cochrane (from inception to January 3, 2014) databases using the following search string: "atrial fibrillation" AND ("renal failure" OR "chronic renal disease" OR "dialysis") AND ("stroke" OR "thromboembolism"). The reference lists of the accessed full-text reports were further researched for sources of potential information relevant to this analysis. The authors of full-text reports and abstracts were contacted by e-mail to retrieve additional information.Only longitudinal studies assessing the occurrence of a composite end point of stroke or systemic embolism (and including transient ischemic attack) during follow-up in patients with AF were considered for inclusion. Both registries and randomized trials were considered eligible for analysis. The methods sections of evaluated studies were reviewed to confirm the suitability and composition of the reported end point. Studies assessing only stroke (either ischemic, hemorrhagic, or a composite of both) and providing no data on systemic embolism were not considered representative of the full spectrum of thromboembolism in AF and were excluded from analysis. Similarly, studies only reporting stroke or systemic embolism in association with myocardial infarction, hospitalization, or death not due to stroke or systemic embolism were not included.

Cause-Specific Mortality in Patients with Chronic Kidney Disease and Atrial Fibrillation

“…Olesen et al studied 132,372 patients from the Danish general population and noted an increased risk of stroke or systemic thromboembolism in patients with CKD (HR 1.49, 95% CI 1.38-1.59) [28]. Similar results have also been noted in other studies with some reporting higher risk than others and the difference is attributed to the discrepancies in the inclusion criteria [2,15,17,[30][31][32]. Our study results further reaffirm the associations between AF and cerebrovascular disease-related deaths in CKD.…”

Efficacy and safety of warfarin in dialysis patients with atrial fibrillation: a systematic review and meta-analysis

“…Another meta-analysis conducted by Providência et al ,68 2014 to evaluate efficacy and safety of warfarin in chronic kidney disease with nonvalvular AF demonstrated in a subgroup analysis of dialysis patients that warfarin exhibited a protective effect and did not increase risk of bleeding. However, only 1 study with dialysis patients by Olsen et al 56 was included, leading to inconclusive results.…”

Synergic impact of oral anticoagulation control and renal function in determining major adverse events in atrial fibrillation patients undergoing percutaneous coronary intervention: insights from the AFCAS registry

“…A recent meta-analysis provides evidence that warfarin treatment reduces the risk of thromboembolic events in AF patients with CKD [hazard ratio (HR): 0.39, 95% confidence interval (CI): 0.18–0.86, p  < 0.00001] [30]. Indeed, Bonde et al report a significant net clinical benefit for VKA amogst CKD patients at a high risk of thromboembolic events (CHA 2 DS 2 -VASc ≥2) [25].…”